Medical Insurance Associate(4582)

The primary function is to perform duties and responsibilities for the Department of Medicine outpatient clinic. Specifically, this position is to assist patients in receiving the services and tests needed and to ensure that proper procedures are followed in compliance with the various insurance companies to ensure payment of those services. This position works under general supervision and acts as a resource specialist within the Department of Internal Medicine for related clinical staff.

Insurance Duties 80%
1. Independently initiates and completes managed care referrals/pre-authorizations as indicated by patients' needs and insurance requirements in order to secure approval for the patient's ongoing medical care. Enters referrals in the SMS system and links to appropriate appointments.
2. Reviews patient medical records for necessary documentation and disseminates the appropriate information to the managed care organizations in order to secure approval of the referrals.
3. Schedules patients' tests, procedures and referrals to specialty offices through phone calls and EHR to the proper hospital/specialist according to physician orders and the patient's insurance.
4. Prepares lab orders, assigns insurance codes and faxes orders and all necessary information to facility prior to scheduled test.
5. Calls patients to relay dates, times and special instructions for tests and referral appointments. Documents required information into the electronic health record.
6. Acts as liaison and advisor for patients, physicians, hospitals, insurance companies, government agencies and related interested parties regarding proper documentation, referral requests, authorization procedures and verification of factual information regarding patient's insurance and other sensitive issues within the field.
7. Secures additional health information from the patient and/or physician's office as needed, and initiates follow-up discussions with the managed care organizations in order to obtain a review of referrals for medical care. Assigns insurance codes to documentation to ensure proper level of payment.
8. Serves as a patient advocate in obtaining referrals to specialist physicians and health care agencies in a timely manner and directs patients to preferred hospital, laboratory, or agency where appropriate.
9. Reviews and analyzes processing procedures in order to identify potential problem areas and improve processing procedure.
10. Acts as an expert resource on managed care issues. Responds to a variety of questions from patients, nursing staff, physicians, hospitals, and insurance companies concerning the status of referrals and scheduled tests.

Administrative 20%
1. Attends training sessions and conferences to remain current regarding policies and procedures of managed care insurance; attends monthly SIU Managed Care Networking Group meetings to keep abreast of changes.
2. Maintains current information on all participating managed care plans in the clinic area including procedures, coding, etc.
3. Participates in the development of appropriate forms for internal and external use as they relate to referrals.
4. Participates on DGIM EHR team as it relates to the referral process.
5. Provides clinical staff and reception with updates on managed care plan

1. Any one or combination totaling one (1) year (12 months) from the categories below:
   1. College coursework in a health-related field, business administration/management, human resource management, or closely related fields as measured by the following conversion table or its proportional equivalent:
      • 30 semester hours equals one (1) year (12 months)
      • Associate's Degree (60 semester hours) equals eighteen months (18 months)
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.

If you require assistance, please contact the Office of Human Resources at hrrecruitment@siumed.edu or call 217-545-0223 Monday through Friday, 8:00am-4:30pm.

The mission of Southern Illinois University School of Medicine is to optimize the health of the people of central and southern Illinois through education, patient care, research and service to the community.

The SIU School of Medicine Annual Security Report is available online at https://www.siumed.edu/police-security. This report contains policy statements and crime statistics for Southern Illinois University School of Medicine in Springfield, IL. This report is published in compliance with Federal Law titled the

"Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act."

Southern Illinois University School of Medicine is an Affirmative Action/Equal Opportunity employer who provides equal employment and educational opportunities for all qualified persons without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, protected veteran status or marital status in accordance with local, state and federal law.

Pre-employment background screenings required.